Mental Health and Development Flashcards

Question

EPI BULLETS

Answer 1

* 15 to 25 % of kids have sleep initiation issues * 67 % of kiddos with Autism have sleep issues

Answer 2

* Pediatric Intellectual Disability **Prevalence is 3%** * **80 %** of children with ID **have a known aetiology** * 21 % are from perinatal toxin exposure * **55 % are neonatal asphyxia** syndromes * 28 % have CNS malformations * _11 %_ developed from forms of _neglect_ * **Genetic testing** has a **50 % diagnostic yield**

Answer 3

_CPS Endorse Therapies_ * **Parental Behavioural Therapy - *BEST trialed before Rx*** * **Routine Exercise - *Excellent impact as per several studies*** * **Shared Decision Making - *Goal directed (School vs. Friends etc.)*** * Psychoeducational Resources - *BEST if online and by physician* * Daily Report Cards from School - *Beneficial, easily implemented* * Organisational Skill Teaching - *improved behaviours and school* * Cognitive Skill Teaching - *Benefits seen by parents, not teachers* _CPS is Indifferent_ * Behavioural Peer Interventions - *Adult studies show benefit* * Dietary Changes - *CPS wants routine diet evaluation (Fe, Vitamins etc)* _CPS does not Endorse_ * EEG Neurofeedback - *Studies show mixed efficacy, more data needed* * Social Skills Teaching - *no benefit*

Answer 4

_The 18 Months Well-baby Visit_ * Assess **growth** and **nutrition** *(milk intake, diet diversity)* * **DTaP-IPV-HiB** vaccination *(re-visit vaccine status if not vaccinated)* * Standardized **developmental assessments** *(ASQ, PEDS, Rourke)* * Address **literacy** and current reading activities * **Parental** Mental **Health**/Medical comorbidity review *If there are any concerns, arrange a firm follow-up date as there are no pre-scheduled follow-ups until the child has already entered school*

Answer 5

_Developmental Impact of Parental Depression on Children_ * Infant * Insecure **attachment** * Dysregulated **arousal** * Dysregulated **attention** * Negative **affect** * Toddler * **Disinhibitions** and social deficits * Abnormal **Internalizing/Externalizing** behaviours * **Cognitive** deficits * School Aged Child * **ADHD** and **Conduct** Disorder * Mood, Anxiety and Learning disorders

Answer 6

_ASD Diagnosis in 12 - 18 months_ * **No** single **words** +/- compensatory non-verbal/grunting * No experience **sharing** * **No imaginative** play Management * Assess **hearing** and **vision** * Screening **metabolic** and **genetic** bloodwork * History for Risk Factors for Autism (Peri-natal, Fhx, exposures) * Referral to Developmental Pediatrics/Multidisciplinary Eval. * Follow-up monthly

Answer 7

_Crying Through the Ages_ * Infant - **Consistent** response to build sense of safety, do not ignore * Toddler - **Consistent** explanations of context, permit * School Age Child - **Consistent** teaching around events leading to * Teenager - **Consistent** support and teaching around events leading to *The CPS, APA and HippoEd highlight consistency of practices between parents as having the best evidence for positive outcomes in discipline, eating behaviours, agggressive behaviours and emotional regulation. Get every one the same page.*

Answer 8

**FALSE** ## Footnote There's no strong evidence to support witholding ADHD stimulant therapy in children congenital cardiac disease, including arrythmias. Children with positive questionaires for sudden cardiac death need to see a Cardiologist and get an ECG - but this should NOT delay access to treatment for their ADHD.

Answer 9

_DSM-V Criteria for Inattentive ADHD_ Criteria A: Persistent behaviours that meet 6 / 9 of the following * Missed details/**careless mistakes** * **Cannot sustain** attention * **Does not** appear to **listen** during conversation * Does not **follow**-**through** with commitments * **Cannot organise** tasks/activities * **Avoids** tasks requiring **sustained mental effort** * **Loses things** associated with a task *(e.g. pencils, stationary)* * Easily **distractible** * Forgetful regarding daily activities Criteria B: Symptoms are present **before 12 years old** Criteria C: Symptoms in **2+ settings** *(e.g school, home, friends, sports)* Criteria D: **Negative** impacts educational and social **functioning** Criteria E: Symptoms are **not secondary** to **another DSM-V Dx**

Answer 10

_Referrals for ASD Assessment must include_ * **Clinical** observations of **signs** or **symptoms of ASD** * Ante**natal** and perinatal **histories** * Developmental **milestones** achieved *(highlight regressions)* * **Risk factors** for ASD * Medical **history** and **investigations** * **Original** reports/**documentation** from previous assessments and concerns from Parents/schools

Answer 11

* Assure patient has filling supper (**No bedtime hunger**) * **Consistent** Sleep and Wake Times * **Relaxing** activities leading up to bedtime * No nicotine, drugs, ethanol, caffeine in the evening * **Dark** Room/**No** **Screens** * Age appropriate **Sleep Duration**

Answer 12

There is an endorsed resource page on the CPS for each province **Know it exists**/how to find it Know your province's resources [**https://www.cps.ca/first-debut**](https://www.cps.ca/first-debut)

Answer 13

_The CPS Endorses the Following_ * TripleP Parenting - *~ 100 - 200 CAD, Available Online\** * Strongest Families - *Free enrollment, **huge waiting list*** * The Incredible Years - *Many languages, **\> 1000$ cost*** *\*Some insurance plans will cover TripleP, encourage families to ask with their providers.*

Answer 14

**NONE** ## Footnote These are all neurologic signs of concussion * Headache * Nausea/vomiting and dizziness * Visual disturbances or photophobia * Phonophobia * Loss of consciousness or amnesia * Loss of balance or poor coordination * Decreased playing ability

Answer 15

**Typically TRUE** ## Footnote Psychostimulants have a dependable **tachyphylaxis** phase after started in a _stimulant naive_ person. After exposure, there is a therapeutic effect which will diminish as the liver up-regulates metabolic enzymes targetting the drug. We account for this with: 1. **Consistent** objective **re-assessment**s of symptoms 2. **Increasing** dose **accordingly**

Answer 16

* **27 % of kindergarten kids** score **vulnerable** on the EDI's developmental screen * For every 1 % of excessive developmental vulnerability identified in EDI - there is a 1 % prospected decline in Gross Canadian Product over the generation's working lifetime.

Answer 17

_ASD Diagnosis in 6 - 12 months_ * **Blunted** or no apparent **joy** * **No reciprocity** in sounds/facial emotion * **No eye contact** but still tracking * Does not respond to **name** * Unusual **play** and possible **stereotypes** Management * Assess **hearing** and **vision** * **History** for Risk Factors for Autism *(Peri-natal, Fhx, exposures)* * Follow-up **Q3months** *+/- developmental peds referral*

Answer 18

_CPS' Troubleshooting of ADHD Treatment_ 1. **Re-assess diagnosis** of ADHD *(Anxiety? ASD? Learning d/o? Mood?)* 2. **Appraise** compliance/access to **behavioural therapies** 3. **Increase** dose of _current_ stimulant 4. Offer the option to **switch to** **another stimulant**\* class or dosing formulation *(brands do matter in psychostimulants)* 5. **Consider** adding a **second-line** therapy *(SNRI, Intuniv)* *\*The CPS strongly reinforces the importance of trying different stimulants before switching to a second -line therapy. There is a lot of variablility in the delivery systems of these drugs, resulting in different responses in different patients.*

Answer 19

_DSM-V Criteria for Autism Spectrum Disorder_ * Criteria A: Impaired Communication/Socialization - *all 3 required* * Blunted or Absent Social/Emotional **reciprocity** * Impaired **non-verbal** **interactions** *(expressed and received)* * Failure to develop **relationships** * Criteria B: Restricted or Repetitive Behaviours *(2/4 needed)* * **Stereotyped** speech or behaviours *(e.g. echolalia or car lining)* * Resistance to Change (**Sameness**) * Restricted and **fixated interests** * **Sensory dysfunction** *(hypersensitive or hyposensitive)* * Criteria C: Must be present during **early developmen**t * Criteria D: Negatively **impact** daily **functioning** * Criteria E: Not Global Dev. Delay or Intelectual Disability\* *\*These can occur as comorbidities, but the symptoms used for diagnosis must not be secondary to these noted deficits; e.g. repeated behaviours from CP lesion are not stereotypes or fixation on Paw Patrol for profound ID can not be restrictive.*

Answer 20

_When to Consider Retiring from Sports_ * When injuries occur with **less force** *(e.g. dislocation, concussion)* * **Symptoms are increasing** in severity *(anticipated limp, headache)* * Athlete’s **style/position/sport predisposes** to injuries * Occurs in the setting of a concomitant **learning disability** or persistent cognitive symptoms *(concussion specific)*

Answer 21

Inadequate **volume** and **quality** of sleep with **negative impact** on daytime **functioning**. In children this manifests with: * Depressive symptoms * Anxious symptoms * Irritability * Poor school performance/attention

Answer 22

When your eyes are **exposed to the dark**, in the right environment, the **pineal gland** secretes **melatonin to** fire up the sleep count-down. This need for dark is where the issue with screen-time (blue light) comes from. Several studies have shown **NO** development of psychiatric, metabolic or behavioural **issues** secondary to melatonin.

Answer 23

_Medical Management_ 1. Assess **hearing** and **vision** 2. CBC, extended electrolytes and **metabolic/nutritional** testing for abnormal eating patterns including **Lead** *(esp. Pica behaviours)* 3. Educate on **injury prevention** as per patient's abnormal behaviours *(e.g. wandering, objects in mouth, biting ...)* 4. **Microarray** and Fragile X 5. Assess for psychiatric **comorbidities** *(ADHD, Anx., Mood d/o)* _Psychosocial and Developmental Management_ 1. Referral to respite and **school-planning services** early 2. **SLP/OT/ABA referrals** immediately when appropriate 3. **Appraise Parents** for coping issues routine 4. **_Re-assess Diagnosis_** routinely as child grows

Answer 24

_The CPS' ABCs of Parenting_ * **A**sk questions * **B**uilding on each family's specific strengths of relationship * **C**ounsel with family-centered guidance * **D**evelop plans for bad behaviours *(sleep, aggression, sharing, eating)* * **E**ducate on positive parenting

Answer 25

_Obvious Autism_ * **Can** apply **diagnosis** with pediatric evaluation * May r**einforce with** standardized **testing**\* * This may **not be enough** for ASD Services _Uncertain or Mild or Atypical Autistic features_ * **Standardized testing**\* * If evident from testing, can diagnose in clinic * Consider **referral** to Developmental/Psychiatric Peds _Complex neurologic/psychiatric comorbidities_ * Refer to multidisciplianry **ASD Diagnostic Team** *All developmental concerns require a STACER-level complete H/P. Hearing and vision testing must also be done before ASD can be diagnosed. \*Tests include ADOS-2 (needs training/certification), CARS-2, ADI-R, 3di, DISCO etc.*

Answer 26

_Pre-Natal Risk Factors fro ASD_ * **Parental Age** \> 35 years old * Maternal **Obesity**, Diabetes or hypertension * *In utero* **valproate** or **pollution** exposure * Fetus-relevant **maternal infections** *(e.g. Rubella, zika)* * **\< 12 months** between **pregnancies**

Answer 27

_DSM-V Criteria for Hyperactive ADHD_ Criteria A: Persistent behaviours that meet 6 / 9 of the following * **Fidgets** or squirms in seat * **Leaves** position when asked to stay put (e.g. classroom seat) * **Runs or climbs** about when socially inappropriate * **Cannot** engage in **leisure** activities **quietly** * Is not comfortable being still or always **"on-the-go"** * **Talks excessively** * **Blurts** out **answers** before questions complete * Difficulty waiting their **own turn** * **Interrupts** or intrudes in others' social contexts Criteria B: Symptoms are present **before 12 years old** Criteria C: Symptoms in **2+ settings** *(e.g school, home, friends, sports)* Criteria D: Negative impacts educational and social **functioning** Criteria E: Symptoms are **not secondary** **to another DSM-V Dx**

Answer 28

1. Clarify issues of **Sleep Initiation vs. Maintenance** 2. Optimize Sleep **Hygiene** 3. Consider off-label **Melatonin trial.** DO NOT use \< 2 y.o. *(Dosing is 0.05 mg/kg Q30-60min PRE-HS)* 4. If ADHD is present, warn parents that efficacy may wane with time if sleep hygiene isn't maintained. 5. Dependance will develop, so **wean when you stop.**

Answer 29

_Parent and Teacher Polled Resources_ * ADHD Rating Scale IV (**Du Paul**) - $ - **Preschool approved** * **Conners** Rating Scales - $ - **Preschool approved** * **SNAP-IV** Teacher and Parent Rating Scale - 5 - 18 years _Patient/Parent Polled Resources_ * Adult ADHD Rating Scale (**ADHDRS**) - late teens * $ means it must be purchased for licensed use, otherwise resources are free online. These resources can be referenced in facilitating ADHD diagnosis or refuting it.*

Answer 30

Before Diagnosing anything Developmental, check for * **Hearing** deficits * **Vision** deficits * **Lead** poisoning\* *\*Risk stratification for Lead poisoning rather than empiric serum measurements. Ask about living conditions, family history of hematologic/sibling development problems, physical exam findings.*

Answer 31

* Noncompliance : **Defies** commands to perform a task ## Footnote * Problematic when these defiances place the child in danger (eat poison, run in street)* * Aggression : **Physical** when frustrated, angry or upset * Problematic when this tactic is used to obtain something they want, or becomes physically violent outside of self-defense* * Temper loss : Has a **tantrum** when tired, hungry or sick * Tantrums are daily or last **\> 5 minutes***

Answer 32

1. The specific disorder *(e.g. gen. anxiety d/o, specific mutism)* 2. **Severity** *(mild, mod, sev.)* 3. **Persistence**/Timing *(e.g. Intermittent, seasonal)* 4. Impact on **functioning** *(e.g. friends, school, play)* *e.g. Mild general anxiety disorder with symptoms associated with the school year, that impact learning and socialisation.* ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis

Answer 33

**Key components for an assessment of Anxiety** 1. Patient history and **parent-reported symptoms/functioning** 2. Focused medical, developmental and mental **health history** 3. Results from standardized **assessment tools***(e.g. SNAP4, WFIRS-P)* 4. Review of **previous consultations** from specialists 5. **Direct observation** of the child and parent-child interactions *It's literally just how you do any consultation in medicine* ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis

Answer 34

Screen for Child Anxiety Related Disorders (SCARED) ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis

Answer 35

**Differential Diagnoses for Anxiety** * Temperament and Emotional regulation development *(physiologic)* * Adverse Childhood Experiences *(i.e. pediatric PTSD)* * School Problems *(e.g. bullying, or learning disabilities)* * ADHD *(25 % of kids with ADHD also have anxiety when screened)* * Tics and Obsessive compulsive disorder * Autism * Eating Disorders *(anxious focus is the body/impact of eating)* * "Somatic symptom disorders" *(how they describe hypochondriac behaviours)* ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis

Answer 36

The CPS gives the attached table which highlights the key components of the behaviours that make the characteristically due to anxiety * **Persistence** *(Recurrent behaviour or lingering concern)* * Impacting **functioning** *(e.g. schoolwork, play, socialisation)* * **Somatization** *(e.g. excessive palpitations, syncope, catatonia)* ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis

Answer 37

**Parenting Tips for Anxious (and all) Children** 2. Identify and **name feelings** 2. **Avoid avoidance** of discussing feelings 3. Validate fears but **do not reinforce** *(e.g. "this is scary, **but** you can do it!")* 4. **Engage** in child-led activities // stay connected/aware of adolescent interest and activities 5. Foster self-confidence *(i.e. language that is focused on them)* 6. **Encourage opinions** and smart choices 7. Break challenges into smaller, manageable pieces, and praise after each victory 8. **Reward attempts**/approximations rather than fixating on results 9. **Model coping techniques** 10. Connect with the school in case issues arise 11. Have **prepared, consistent, smooth routines** for school/summer camp 12. **Model positive ways of handling conflict** ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-management

Answer 38

**Managing Anxiety** 1. Psychoeducation *(e.g. pamphlets, PPP Parenting)* 2. **Psychotherapy** *(CBT has an OR of 5.45 for anxiety remission)* 3. Pharmacotherapy * SSRI and SNRI for ages **6-18 years** * **Re-assess** tolerance, dose and response every **2 weeks** * Avoid Paroxetine 4. School Outreach *(Establish an IEP and re-evaluate as symptoms improve)* ## Footnote https://cps.ca/en/documents/position/anxiety-in-children-and-youth-management

Mental Health and Development Flashcards

Updated 01/04/2024 (63 cards)